Not worth it
Ruptured abdominal aortic aneurysms (AAA) rarely end well. But ultrasound scans can detect them before they pop, and elective repair has 95% survival, so they may justify screening. On the other hand surgery is expensive, especially on the sort of overweight smokers who are at most risk of AAA, they don’t all burst, and keeping a watch on the borderlines stresses people out, so screening might do more harm than good. Fortunately we have evidence.
Three large randomised controlled trials have conclusively shown, at least for men aged over 65, that screening saves lives (click here). About 200 men need to be scanned for each life saved, at a net cost according to the NHS experts of about £100 per man screened or £7,600 per additional year of life in full health – Quality Adjusted Life Year or QALY in the jargon. This is better value for money than many other NHS treatments (details here). In about six years I’ll get an invitation. What’s not to like?
The trouble is the cost benefit analysis is flaky. A recent paper (click here) found seven economic models of AAA screening all based on the same trial evidence. The cost per QALY varied from €4,000, in an analysis from the UK (click here) to €57,000 per QALY in one from Denmark (click here). The review authors reckoned the differences were due to different assumptions within each model, which outside observers cannot easily judge as correct or not. I can’t contribute to that sort of technical discussion, but I can see one big flaw in those models I can understand.
None of the models include the cost of success. Ruptured aortic aneurysm is usually a quick way to go. About half simply drop dead, and at least half the rest die after a few days in hospital. If this quick death is prevented by screening, the patient still has to die of something. Since most deaths are slow, it’s likely to be more expensive, much more if it’s Alzheimers. Even the successfully treated man who lives into his 90′s is spending his pension, rather than generating wealth. Once we stop working we cost less dead. If I’m right all the models underestimate the costs substantially.
There’s another reason to doubt the lower cost estimates – why isn’t there a free market AAA screening programme aimed at moderately wealthy old geezers? £100 per man screened is not much for a person on even a modest pension. Plenty of countries with rich people in them don’t have state-funded screening programmes. If the net cost was really £100 per punter there should be money to be made offering scan/operation packages. Nowhere in the world are private practitioners offering AAA screening to the uninsured for £100 a pop – excuse the pun – or anything like it.
Lack of a private service should give the NHS cause for thought. If no middle class men anywhere, fork out for AAA screening, why should we believe some economist who is essentially saying they they don’t know what’s good for them.
But perhaps I’m wrong. Maybe it really is as cheap as the health economists say. I still object to paying for it.
Whatever happened to the idea of deserving and undeserving patients. It may be politically unacceptable to say that some people deserve health care more than others, but it doesn’t make it less true. I’d rather spend money on a cancer treatment for teenagers that cost £20,000 per QALY, than on AAA screening at £7,600 per QALY. A year of life at 20 is worth more than one at 70, and if you’re struck down through no fault of your own, you’re more deserving than an old geezer who’s been smoking, boozing and overeating half his life.
Larkin had told many friends about feeding the hedgehog in his garden and was devastated when he accidently killed it. But note the “twice” in line 1, an unsentimental Larkin detail. Without realising what was happening, he had restarted the motor and finished it off.
Aside from scraps composed for retirements and anniversaries, this is the last poem he wrote. I’m glad that his final poetic comment on death was not the terrifying Aubade but these tender thoughts on a hedgehog.
The mower stalled, twice; kneeling, I found
A hedgehog jammed up against the blades,
Killed. It had been in the long grass.
I had seen it before, and even fed it, once.
Now I had mauled its unobtrusive world
Unmendably. Burial was no help:
Next morning I got up and it did not.
The first day after a death, the new absence
Is always the same; we should be careful
Of each other, we should be kind
While there is still time.
Authors have links to manufacturers and no expertise in evidence synthesis
The British Menopause Society’s 2013 recommendations on hormone replacement therapy (click here) is biased in favour of the wider prescribing of HRT. For example:
Arbitrary limits should not be placed on the duration of usage of HRT; if symptoms persist, the benefits of hormone therapy usually outweigh the risks.
HRT prescribed before the age of 60 has a favourable benefit/risk profile.
Compare this with the UK Medicines and Healthcare Products Regulatory Agency (MHRA)’s current advice:
For all women, the lowest effective dose should be used for the shortest time.
Or the US Federal Drug Administration
If you decide to use hormones, use them at the lowest dose that helps. Also use them for the shortest time that you need them.
The authors choice of references is also biased. For example they cite a press release from the unpublished KEEPS study as suggesting that there is no cardiovascular harm from HRT begun soon after the menopause, but fail to mention these two papers in the BMJ and Lancet (click here and here) suggesting an increased cardiovascular risk.
Disappointingly, the Royal College of Obstetricians and Gynaecologists (RCOG) has endorsed this nonsense (click here) without mentioning the authors’ or the society’s conflicts. Perhaps that is because the authors of the report don’t list their conflicts either. So here they are:
Nick Panay, Lead author – consultancy, advisory and honoraria Pfizer, Bayer, Abbott. (click here) plus Baxter, Schering, Eli Lilly, Galen, Janssen Cilag, Merck, Novo Nordisk, Novogen, Organon, Orion, Procter & Gamble, Se-cure, Servier, Shire, Solvay, Storz, and Wyeth (click here).
The trustees and council of the British Menopause Society also include:
Janice Rymer, Organon (click here) and Wyeth, Janssen-Cilag and Pfizer (click here)
John Stevenson Schering Plough, Wyeth/Pfizer, Bayer, Meda and Merck/Theramex. (click here)
John Studd, Procter & Gamble (click here)
David Sturdee, Amgen, Theramex, Procter & Gamble, Wyeth, Bayer Schering and Novo Nordisk. (click here)
There are no published conflicts of interest for the other three authors Haitham Hamoda, Roopen Arya or Michael Savvas. However, none of them have previously performed an evidence-based review.
Naive women who visit the RCOG website in search of advice about HRT should be aware that the review they get directed to is written by authors with links to the HRT manufacturers who have no experience of evidence synthesis.
The Cochrane Library is a better source of information. Its systematic review of menopausal hormone therapy (HT) and cardiovascular disease (click here) concludes:
Treatment with HT in post-menopausal women for either primary or secondary prevention of CVD events is not effective, and causes an increase in the risk of stroke, and venous thromboembolic events. HT should therefore only be considered for women seeking relief from menopausal symptoms. Short-term HT treatment should be at the lowest effective dose, and used with caution in women with predisposing risk factors for CVD events.
A rather different message!
From the New Yorker, November 25, 2013.
Click here for Sad Song
The Day Lou Reed Died
It’s not like his songs are going to simply
but since the news I can’t stop
listening to him
on endless shuffle—familiar, yes, inside
me, yes, which means
I’m alive, or was, depending on when
you read this. Now
a song called “Sad
Song,” the last one on Berlin,
sung now from the other side, just talk,
really, at the beginning, then
or threat, I’m gonna stop wasting
my time, but what else
are we made of, especially now? A chorus
sings Sad song sad song sad song sad
knew him better than I knew my own
father, which means
through these songs, which means
not at all. They died on the same day, O
what a perfect day, maybe
at the same moment, maybe
both their bodies are laid out now in
the freezer, maybe side by side, maybe
holding hands, waiting
for the fire or the earthor the man
or the salt—
if I could I’d let birds devour whatever’s left
& carry them into the sky, but all I can do
is lie on the couch & shiver, pull a coat
over my body as if it were all I had, as if I
were the one sleeping outside, as if it were my
body something was leaving, rising up
from inside me
& the coat could hold it inside
maybe a little longer.
Larkin to Monica Jones: “I thought you might like to see this – I don’t know who else will, as it isn’t really publishable [...] it was inspired by the photo on The Listener cover a week or so ago of a rhesus monkey & her baby monkey [...]. It carried that complete & utter condemnation of the human race monkeys seem to be able to convey. It was accompanied by accounts of fatuous American experiments of taking baby monkeys away from their mothers & noting that they are unhappy.”
Composed between 12 and 24 February 1965, and unpublished in Larkin’s lifetime, this first appeared in Complete Poems (1988), under the title Ape Experiment Room. Archie Burnett argues for the present title.
Presumably risk of libel, rather than quality or subject made it unpublishable. The break between verses, and the diversion about the experimenter’s wife, around which the horror builds, are pure Larkin.
Buried among white rooms
Whose lights in clusters beam
Like suddenly caused pain,
And where behind rows of mesh
Uneasy shifting resumes
As sterilisers steam
And the routine begins again
Of putting questions to flesh
That no one would think to ask
But a Ph.D. with a beard
And nympho wife who -
There, I was saying, are found
The bushy T-shaped mask,
And below, the smaller, eared
Head like a grave nut,
And the arms folded round.
Footnote - According to Archie Burnett, The Complete Poems p 634, the experimenter was Dr Harry F Harlow, Director of the Primate Research Laboratory at the University of Wisconsin.
Harlow was a famous experimental psychologist. He is credited by some with re-emphasising the importance of the mother-infant bond against the theories of the behaviourists at the time. Maybe so, but he also seemed to delight in the awful nature of his experiments. See for example, Harlow HF, and Suomi SJ (1971) Social Recovery by Isolation-Reared Monkeys, Proc Natl Acad Sci; 68: 1534–1538 (click here): “By methods dark, dismal and devious we impregnated several of these reluctant females over a period of years”.
He married three times, albeit only two women. First his student, Clara Mears, by whom he had two children. In 1946 he divorced Clara and married another psychologist, Margaret Kuenne, and had two more children. When Margaret died in 1971 he remarried Clara. He died in 1981.
A mixed bag.
“What’s terrible is to pretend that second-rate is first-rate. To pretend that you don’t need love when you do; or you like your work when you know quite well you’re capable of better.” From The Golden Notebook
On feminism: “Contemporary women scream or swoon at the sight of a penis they have not been introduced to, feel demeaned by a suggestive remark and send for a lawyer if a man pays them a compliment.”
On hearing that she had won the Nobel prize for literature. “Oh, Christ! I couldn’t care less.”
On the 9/11 attacks: ”September 11 was terrible, but if one goes back over the history of the IRA, what happened to the Americans wasn’t that terrible.”
“I do not think that marriage is one of my talents. I’ve been much happier unmarried than married.”
“Do you know what people really want? Everyone, I mean. Everybody in the world is thinking: I wish there was just one other person I could really talk to, who could really understand me, who’d be kind to me. That’s what people really want, if they’re telling the truth.” From The Golden Notebook
“Very few people really care about freedom, about liberty, about the truth, very few. Very few people have guts, the kind of guts on which a real democracy has to depend. Without people with that sort of guts a free society dies or cannot be born.” From The Golden Notebook.
“There is no doubt fiction makes a better job of the truth.” From Under My Skin.
By Lia Purpura
This short poem about eternity appears in the New Yorker, 18 November 2013. The punning title sets it up. The final line makes it.
Where you were
before you were born,
and where you are
when you’re not anymore
might be very close.
Might be the same place,
though neither is
as being here but
you will have been—
that point where things land,
are finished, over, and
gone but not yet.
by Lia Purpura